Application for the issue of or a change to a UK Design Organisation Approval (DOA) in accordance with Part 21 subpart J.

Transcription

1 Application for the issue of or a change to a UK Design Organisation Approval (DOA) in accordance with Part 21 subpart J. Please complete this form online (preferred method) then print, sign and submit as instructed. Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink. FALSE REPRESENTATION STATEMENT It is an offence under the UK Air Navigation Order to make, with intent to deceive, any false representation the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document. This offence is punishable on summary conviction by a fine and or up to two years imprisonment. Please complete either section 1 a) or section 1 b). For all registered Companies, please complete section 1 b) only. 1. APPLICANT DETAILS (The Applicant is the person responsible for payment of CAA charges) a) Individual (including sole traders and partnerships) Title:... Forename:... Surname:... Address: Postcode:... Telephone:... Fax: Trading Name: (if applicable)... Website address:... In the case of a partnership, please complete details of all partners. Continued on a separate sheet or b) A Company Registered Company Name (in full):... Company Registration Number:... Country of Company Registration:... Registered Office Address: Postcode:... Telephone:... Fax: Trading Name: (if applicable)... Trading Address (primary site): Postcode:... Website address:... This application will be considered in respect of and, if appropriate, granted to, the company registered under the Company number provided on this form. Form SRG1765 Issue 01, December 2018 Page 1 of 6

2 or c) An Unincorporated Association or other body Name of Unincorporated Association or other body:... Address:... Country:... Telephone:... Postcode:... Fax: Mobile Telephone:... Website address:... Authorised Representative:... This application is to be signed by a person or persons authorised by the body named above to act on behalf of it. This should normally be a member or members of the managing committee of the association or other body. Evidence of the authorisation to act on behalf of the association or body should be provided with the application. Title:... Forename:... Surname:... Position:... Charity Number (if applicable): APPLICABILITY This form is for the issue of or a change to a Design Organisation Approval. Please complete each section of this form relevant to your application. Sections that do not require completion should be left blank. Please use the continuation box 7 where required. 3. NATURE OF APPLICATION (Please tick applicable boxes) Part 21J (DOA) Design Organisation Approval Initial Approval Change of Company/ Trading Name* Change to existing approval Part 21J (DOA) Approval Categories: i) Type Certificates ii) Supplemental Type Certificates (STC) / Major Repairs iii) Minor Changes / Minor Repairs Part 21J Alternative to Design Organisation Approval (ADOA) Part 21J (ADOA) Approval Categories: i) Equipment Approval Where applicable, please detail the scope of approval relevant to your application in Section 7. *Change of Company/Trading Name of the approval holder applies where the Company Number remains the same. If the Company No. changes a new approval will be required. Approvals granted to a sole trader/individual are non transferable. Form SRG1765 Issue 01, December 2018 Page 2 of 6

3 4. APPLICATION REQUIREMENTS(Please tick applicable boxes) Please submit the following information to enable the CAA to complete the application investigation. Failure to provide any of the required information will result in the application being rejected and a fresh application will require to be submitted. Attached 1) Copy of EASA Approval Certificate 2) Copy of EASA approved Design Organisation Handbook (including any associated listings or referenced procedures) 3) Copy of EASA Approved Form 4 for all nominated staff 4) A copy of the latest audit report(s) from the EASA containing all outstanding findings and related corrective action plan, as well as enforcement actions (if any). 5) A completed organisation internal Audit Report (including objective evidence) to confirm the organisation is complaint to applicable regulation. 6) A completed CAA Regulation (EU) No 376/2014 Compliance Checklist 7) A copy of the company Certificate of Incorporation if your organisation is trading as a registered company. 8) A completed SRG 1760 form (Principal Place of Business Key Facts form) if your organisation is trading as a registered company 5. Change of Company/Trading Name Please submit a copy of your company s Certificate of Incorporation for new approval applications and changes to company names where applicable. CAA Approval Numbers affected by the Change of Company/Trading Name):... Existing Company/Trading Name:... New Company/Trading Name: Change to Existing Approval (Inclusion of new site) Site 1: New or additional site address: Postcode:... Telephone:... Fax: Web address:... Site 2: New or additional site address: Postcode:... Telephone:... Fax: Web address:... Form SRG1765 Issue 01, December 2018 Page 3 of 6

4 7. CONTINUATION BOX 8. SUBMISSION INSTRUCTIONS When you have completed this Form, please send it to: Shared Service Centre Aviation House Gatwick Airport South West Sussex RH6 0YR Form SRG1765 Issue 01, December 2018 Page 4 of 6

5 9. CHARGES The charge(s) required as calculated in accordance with the CAA Airworthiness Scheme of Charges (published in CAA Official Record Series 5) to be paid on application are enclosed herewith. NB: This application will not be processed until the applicable fees have been received. Total fees included are:... IMPORTANT NOTES: Where the cost of the CAA investigations exceeds the application charge payable, the applicant shall pay additional charges to recover those excess costs incurred by the CAA in accordance with the Scheme of Charges. If a Member or employee of the CAA is required to travel overseas in respect of this application you are advised to read the CAA Scheme of Charges to which this application relates and the section entitled 'Additional charge where functions are performed abroad'. All expenses incurred in pursuance of this application by virtue of travelling overseas will be payable by the applicant on demand. In the event that this application is withdrawn by the applicant, a cancellation charge may be levied. The cancellation charge reflects the work carried out by the CAA on behalf of the applicant up to the point of cancellation. Please see the CAA Refunds Policy at for more information. Where sufficient funds remain from the original application fee, this charge will be deducted from any refund made in respect of the application following cancellation. 10. FINANCIAL DECLARATION I hereby declare that to the best of my knowledge the particulars entered on this application are accurate. I enclose the charges payable on application in accordance with the Scheme of Charges ( I agree to pay any additional charges which may become payable in respect of this application under the Scheme of Charges. Name of Applicant:... (as shown in 1 a) or 1 b)) Signature of Applicant (named in 1 a or 1b)):... Date:... CAA USE ONLY Applicant s name... Date of application... Department:... Contact Name:... Job No:... Folio No:... CAA Account Number:... Nominal Code:... Cost Centre:... Date received.... If payment is received by cheque, attach a copy to this application form. The sum of... has been received by:... Date:... Amount paid by: Cheque Cash Card Electronic Transfer* * Receipt of Electronic Transfer to be verified by Treasury. Cheque drawn against account of:... Bank Account No:... Sort Code:... Form SRG1765 Issue 01, December 2018 Page 5 of 6

6 Payment Authorisation This form can be filled in on screen (preferred method) then printed, signed and submitted as instructed. Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink 1. APPLICANT DETAILS (The Applicant is the person responsible for payment of CAA charges) Application for:... Dated:... Original Applicant s Name:... Application Submission Number (ASN):...or, Application form number (i.e SRGxxxx)... Registered Company or Trading Name: (if applicable)... Contact Telephone Number: PAYMENT DETAILS a) Payment type (please tick your chosen method of payment). Visa Mastercard Debit Card Cheque/Banker s Draft Bank Transfer Cash (max. 1000) The maximum single transaction using a Visa/Mastercard or Debit Card is limited to 25,000. We do not accept American Express, Diners Club or JCB cards. Cash payments will only be accepted in person at Aviation House, Gatwick. Please do not send cash by post. Cheques shall be made payable to 'Civil Aviation Authority'. Please write the CAA Application Form No. on the reverse of your cheque. National Westminster Bank plc Bloomsbury Parr s Branch Account Name: Civil Aviation Authority PO Box 158 Account Number: High Holborn Sort Code: London Swift Code: NWBK GB 2L WC1V 7BX IBAN: GB90 NWBK Please supply the following information: Amount:... BACS/CHAPS/ASN Reference*:... *When making a bank transfer please instruct your bankers to quote, i) in relation to an offline application, the individual s CAA reference number followed by the application date (i.e A ddmmyyyyy) or ii) in relation to an online application, the Automatic Submission Number (ASN) (i.e. CAI-123). Payer:... Payers ... Date of Transfer:... b) Card Details (for payment by Credit/Debit Card) Card number: Expiry date: / Security Code (last 3 digits on signature strip on reverse of card) Debit cards only: Start date: / Amount:... Issue No: (if applicable) Name (as written on card):... (BLOCK CAPS) Full postal address of card holder: Postcode:... Card holder s signature:... Please tick box if paying with Company Card Company Name:... Do not send credit card details by . If sending this form electronically, please leave this section blank and we will call you to confirm your card details at the time. Form FCS1500 Issue04 February 2016 Page 1 of 1